Evaluating the health outcomes of aging in place: the role of medicaid aging waiver program on U.S. older adults

The Medicaid Aging Waiver program (MAW) subsidizes the cost of long-term care (LTC) at home or in communities to satisfy older people’s increasing desire to age in place. The MAW program might be health improving for older people by allowing them to age at home. However, less quality and quantity of home-based care comparing to nursing home care could offset some of the potential benefits. I use policy expenditure across states over time linked with detailed health information from the Health and Retirement Study (HRS) to identify the associated effects of MAWs on health outcomes of older adults who are at risk of needing LTC and who are resources constrained to be potentially eligible for Medicaid. Overall, the findings suggest that the MAW program is beneficial to health: a $1,000 increase in MAW spending for each older person results is associated with a 1.4 percent improvement in self-reported health status, a 1.5 percent reduction in functional mobility limitations, a 1.6 percent decrease in Instrumental Activities of Daily Living (IADL) limitations, and a 1.7 percent improvement in negative psychological feelings. For older people who are most likely not eligible for MAWs, such as those who are wealthy or in good health and do not require LTC, these health-improving effects have not been observed. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-024-19498-3.


Table A1 :
Relationship Between HCBS in 1998 and Pre-Expansion Health VariablesThe data used are from HRS 1992-1998 of individuals who are aged 65 and older.The HCBS in 1998 is per capita spending of older population.The first column reports the mean of each dependent variable.Column 2 estimates the univariate relationship between HCBS in 1998 and health outcomes. Notes:

Table A2 :
Effect of State Economic Conditions on HCBS

Table A3 :
Effect of Lagged State Economic Conditions on HCBSNotes: The data used are a state-year panel from 1999 to 2014.The unemployment and employment level is from BLS, the state population is from Census Bureau, the GDP, personal income (PI), personal consumption expenditure (PCE) is from the Bureau of Economic Analysis Regional Analysis Accounts.The dependent variable is per capita HCBS spending.Each cell reports estimates from a separate specification.The last column includes lagged income controls such as GDP per capita, PI per capita, and PCE per capita.All regressions include state, year fixed effects and weighted using the state population.

Table A4 :
Effect of HCBS on Other Spending Notes: The data used are a state-year panel from 1999 to 2014.The health care, net health insurance, and life insurance spending is from the Bureau of Economic Analysis Regional Analysis Accounts.All regressions include state, year fixed effects and weighted using the state population.Standard errors are clustered at the state level and shown in parentheses.*** p<0.01, ** p<0.05, * p<0.10.

Table A5 :
The Associations Between MAWs with Health Using Other Cutoffs individual FEs, year FEs, state-specific linear time trends, and demographics of individuals such as age, age squared, marital status, and number of siblings.Standard errors are clustered at the state level.*** p<0.01, ** p<0.05, * p<0.10.

Table A6 :
The Associations Between MAW Expenditures With Other Health Outcomes The data used are from HRS 1998 to 2014 of individuals who are potentially in need of LTC and eligible for MAWs.Each cell reports estimates using equation (1) for each dependent variable.Gross motor skills limitation in column 1 includes items of walking one block, walking across a room, climbing one flight of stairs, getting in or out of bed, and bathing activities.Fine motor skills limitation in column 2 includes items of picking up a dime, eating, and dressing activities.Large muscle limitation in column 3 includes items of sitting for 2 hrs, getting up from a chair, stooping, kneeling or crouching, and pushing or pulling large objects activities.Columns 4 to 7 are dichotomous dependent variables indicating whether individuals have been diagnosed with cancer, lung, heart disease, and stroke.All models control for individual FEs, year FEs, state-specific linear time trends, and demographics of individuals such as age, age squared, marital status, and number of siblings.Standard errors are clustered at the state level.*** p<0.01, ** p<0.05, * p<0.10.

Table A7 :
Robustness Checks of the Results of MAWs on Health with State ControlsNotes: The data used are from HRS 1998 to 2014 of individuals who are potentially in need of LTC and eligible for MAWs.Each cell reports estimates using equation (1) for each dependent variable.Poor health is an indicator showing that an individual self-assesses his or her general health status as fair or poor.Mobility limitation is an indicator of having at least 2 items of limitations in walking 1 block, walking several blocks, walking across a room, climbing 1 flight of stairs, and climbing several flights of stairs.IADL limitation is an indicator of having at least 1 item of limitations in using the phone, managing money, taking medications, shopping for groceries, and preparing hot meals.Depression is an indicator of feeling at least 1 negative emotions in the past two years such as felt depressed, felt alone, felt sad, had restless sleep, felt everything was an effort, could not get going, felt unhappy, and did not enjoy life.All models control for individual FEs, year FEs, state-specific linear time trends, demographics of individuals such as age, age squared, marital status, and number of siblings, and state-level socioeconomic variables such as percentage below the poverty level, education level, percentage female, percentage white, percentage married, personal income per capita, employment rate, and political affiliation of the governor.Standard errors are clustered at the state level.*** p<0.01, ** p<0.05, * p<0.10.

Table A8 :
Robustness Checks of the Results of MAWs on Health Dropping Moving ObservationsNotes: The data used are from HRS 1998 to 2014 of individuals who are potentially in need of LTC and eligible for MAWs and who do not migrate over years.Each cell reports estimates using equation (1) for each dependent variable.Poor health is an indicator showing that an individual self-assesses his or her general health status as fair or poor.Mobility limitation is an indicator of having at least 2 items of limitations in walking 1 block, walking several blocks, walking across a room, climbing 1 flight of stairs, and climbing several flights of stairs.IADL limitation is an indicator of having at least 1 item of limitations in using the phone, managing money, taking medications, shopping for groceries, and preparing hot meals.Depression is an indicator of feeling at least 1 negative emotions in the past two years such as felt depressed, felt alone, felt sad, had restless sleep, felt everything was an effort, could not get going, felt unhappy, and did not enjoy life.All models control for individual FEs, year FEs, state-specific linear time trends, and demographics of individuals such as age, age squared, marital status, and number of siblings.Standard errors are clustered at the state level.*** p<0.01, ** p<0.05, * p<0.10.